ArticleLiterature Review

Subtle Cavus Foot: Diagnosis and Management

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Abstract

The subtle cavovarus foot (SCF) is a mild malalignment caused by either primary hindfoot varus or a plantarflexed first ray, resulting in a typical constellation of symptoms because of altered foot mechanics. Key clinical signs are a peek-a-boo heel and a positive Coleman block test. The cavovarus position places lateral ankle soft-tissue structures, such as the anterior talofibular ligament and the peroneal tendons, on stretch during normal gait. This can lead to common conditions such as lateral ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals and cuboid. The gait cycle is altered because a greater proportion of time is spent with the transverse tarsal joints locked due to the overall varus foot position. In contradistinction to physiologic valgus at heel strike, which maintains the transverse tarsal joints unlocked and affords approximately 50% force dissipation, the increased rigidity of the foot causes a maldistribution of forces that leads to accelerated wear of the midfoot joints and increased stresses along the plantar fascia and the Achilles tendon insertion. Successful nonsurgical management requires correction of the biomechanical anomaly; surgical management of a subtle cavovarus foot typically is part of a comprehensive plan for correcting the symptoms and the malalignment.

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... However, in recent years, the occurrence of its subtle form has become an object of study. In such cases, the deformity is less clear, and the factors that lead to this structural change are unknown (1)(2)(3)(4) . ...
... SCF is diagnosed by observation of the "peek-a-boo" sign (from an anterior view of the patient with feet flat on the floor, the outline of the calcaneus is observed medially to the ankle, demonstrating hindfoot varus), plantar flexion of the 1 st ray and lack of claw toe in most cases. It is differentiated from other types of cavovarus feet due to its subtle changes, absence of obvious varus of the calcaneus in the posterior observation of the feet (hindfoot in neutral position or with slight varus that is difficult to evaluate in the posterior view) and absence of neuromuscular disorders or trauma sequelae (Figures 1 and 2) (1)(2)(3)(4)(5)(6)(7) . ...
... The importance of performing this diagnosis is the fact that SCF involves anatomical changes that become functionally more rigid, and as a result, there are changes to normal gait biomechanics, causing overload in unusual places and a predisposition to injury. This is explained by the fact that the talonavicular and calcaneocuboid joint axes become oblique when the hindfoot is positioned in varus, limiting hindfoot mobility (1)(2)(3)(4)(5)(6)(7)(8)(9)(10) . ...
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Article
Objetivo: Identificar a prevalência de patologias do tornozelo e pé nos pacientes com Pé Cavo Sutil (PCS). Métodos: Esta é uma série de casos retrospectiva. Foram avaliados pacientes com patologias do membro inferior e que ao exame clínico também tiveram o diagnóstico de PCS. Foram excluídos os pacientes com diagnóstico de patologias que poderiam levar a essa deformidade, como sequela de trauma e patologias neurológicas, além da presença de Pé Cavo Varo com deformidade intensa. Foram avaliadas as correlações entre as patologias do tornozelo e pé com a presença do PCS. Resultados: Foram avaliados 119 pacientes (67 do sexo masculino/52 do sexo feminino), totalizando 238 pés. Cento e quarenta e um pés apresentavam Cavo Sutil e 97 pés tinham alinhamento fisiológico. Dos 141 PCS, 76 pés eram à direita e 65 pés à esquerda. Vinte e dois pacientes tiveram PCS bilateral. Foram identificadas 140 queixas, que levaram a 18 diagnósticos: instabilidade de tornozelo (37 casos/26,2%), tendinopatia dos tendões fibulares (31 casos/22,0%), fascite plantar (18 casos/12,8%), tendinopatia do tendão calcâneo (10 casos/7,1%), lesão osteocondral do tálus (7 casos/5,0%), metatarsalgia mecânica (6 casos/4,3%), patologias do sesamoide do hálux (5 casos/3,5%), neuroma de Morton (5 casos/3,5%), Hálux Valgo (5 casos/3,5%), dor na face lateral do pé (4 casos/2,8%), impacto anterior (3 casos/2,1%), dor na face medial da tíbia (2 casos/1,4%), lesão da placa plantar (2 casos/1,4%) e outras patologias com prevalência <1%. Conclusão: Encontramos correlação evidente entre o PCS e a instabilidade aguda e crônica do tornozelo, a tendinopatia dos tendões fibulares e do tendão calcâneo e a fascite plantar. Nível de Evidência IV; Estudos Terapêuticos; Série de Casos.
... 1,13,18 Surgical planning for symptomatic deformities includes assessment of whether deformity originates in the forefoot or hindfoot, and whether it is flexible enough to perform a joint-sparing procedure. 1,10,13,14,18 These parameters have traditionally been assessed by use of the clinical Coleman block test (CCBT). First described by Coleman and Chestnut in 1977 and later studied by Paulos and Coleman in a case series in children, this test involves placing a block under the lateral foot, allowing the first ray to plantarflex freely. ...
... 5,21 The authors postulated that in deformities originating from a plantarflexed first ray, the block negates the "kickstand" effect of the ray. 5,10,20 If the subtalar joint is flexible, the heel may then assume a normal valgus position. ...
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Article
Background Cavovarus foot constitutes a complex 3-dimensional deformity. The Coleman block test has traditionally been used to distinguish between forefoot- and hindfoot-driven deformity. However, there has been no objective evaluation of the Coleman block test using radiographs or weightbearing computed tomography (WBCT). The purpose of this study was to compare hindfoot alignment in adult cavovarus feet with and without the Coleman block using clinical examination, radiography, and WBCT. Methods Six feet in 6 patients with a clinical diagnosis of cavovarus foot deformity were prospectively enrolled. All feet underwent clinical photography with the camera positioned at 0 degrees to the heel, hindfoot alignment view radiography with the beam positioned 20 degrees off the ground, and WBCT, both with and without the Coleman block in place. Clinical photos were characterized using the standing talocalcaneal angle (STCA), radiographs were characterized using the hindfoot alignment angle (HAA), and WBCTs were characterized using manual and automated hindfoot alignment angle (HAA) and foot and ankle offset (FAO). Using paired analyses, measurements taken with the Coleman block in place were compared to those taken without the Coleman block. Finally, the different methods of measuring hindfoot alignment were tested for correlation with each other. Mean age was 56 years (range 38-69). Results On clinical photography, the STCA decreased by 3.8 degrees with addition of the block (from 10.0±6.6 degrees varus without block to 6.2±7.1 degrees varus with block; P = .001). On radiograph, HAA decreased by 9.0 degrees with addition of the block (from 16.8±8.4 degrees varus without block to 7.5±6.3 degrees varus with block; P = .07). On WBCT, hindfoot alignment angle changed an average of 3.2 degrees (33.4 degrees varus without block, 30.2 degrees varus with block; P = .008). On WBCT, FAO decreased by 1.4% (from 11.3% varus without block to 10.1% varus with block; P = .003). Clinical examination and automated WBCT measurements were strongly correlated with each other. Conclusion Clinical examination, radiograph, and WBCT demonstrated improvements in hindfoot varus using the Coleman block test in adults, but no patient demonstrated complete resolution of deformity regardless of the measurement modality. Clinical examination correlated strongly with automated WBCT measurements. Level of Evidence Level IV, retrospective case review.
... As shown in a biomechanical study by Mann RA et al., physiological hindfoot alignment is important to ensure proper distribution of impact forces [9,32]. Hindfoot pathologies, such as a pes cavovarus, may result in greater strain on lateral ankle-stabilising structures during the stance phase [9]. ...
... As shown in a biomechanical study by Mann RA et al., physiological hindfoot alignment is important to ensure proper distribution of impact forces [9,32]. Hindfoot pathologies, such as a pes cavovarus, may result in greater strain on lateral ankle-stabilising structures during the stance phase [9]. Constant malpositioning of the foot and increased forces on the peroneal tendons are believed to significantly influence the emergence of peroneal tendinosis. ...
Article
A painful episode in the region of the peroneal tendons, within the retromalleolar groove, is a common precipitating event of an acute lateral ankle sprain. A forefoot striking pattern is suspected to cause peroneal tendinosis. The aim of this study is to analyse the role of peroneal tendinosis as a predisposing factor for ankle sprain trauma in runners. Fifty-eight runners who had experienced acute ankle sprain trauma, with pre-existing pain episodes for up to 4 weeks in the region of the peroneal tendons, were assessed clinically. Fractures were excluded by conventional radiography. An magnetic resonance imaging (MRI) scan had been performed within 14 days after the traumatic event and was subsequently evaluated by two experienced radiologists. MRI revealed peroneal tendinosis in 55 patients (95 % of the total study population). Peroneus brevis (PB) tendinosis was found in 48 patients (87 % of all patients with peroneal tendinosis), and peroneus longus (PL) tendinosis was observed in 42 cases (76 %). Thirty-five patients (64 %) had combined PB and PL tendinosis. A lesion of the anterior talofibular ligament was found to be the most common ligament injury associated with peroneal tendinosis (29 cases; 53 %), followed by a lesion of the calcaneofibular ligament (16 cases; 29 %) and a lesion of the posterior tibiofibular ligament (13 cases; 24 %). The results of this study reflect the correlation between peroneal tendinosis and ankle sprain trauma. Injuries of one or more ligaments are associated with further complications. A period of rest or forbearance of sports as well as adequate treatment of the peroneal tendinosis is essential to prevent subsequent ankle injuries, especially in runners. Modification of the running technique would also be beneficial. IV.
... No se aborda aquí el amplio tema del pie cavo; no obstante, desde hace algunos años, se admite que en el límite entre el pie cavo y el pie normal existiría un morfotipo de pie denominado por los anglosajones subtle cavus foot [5] (Fig. 4). ...
Article
Resumen La insuficiencia del primer radio se define como la incapacidad del primer metatarsiano para desempeñar su papel de soporte a nivel del antepié. Corresponde a un síndrome cuyas manifestaciones clínicas a nivel del antepié son múltiples, todas ellas secundarias a una transferencia de carga a la parte lateral del antepié: síndrome de segundo radio, metatarsalgias, neuroma de Morton. Esta discapacidad suele ser la consecuencia de un defecto de longitud, absoluto o relativo, del primer metatarsiano, que puede ser primario o secundario. La exploración podológica más o menos completada con un estudio radiológico simple permite establecer el diagnóstico y definir la etiología. Si no existe una relación evidente entre la insuficiencia del primer radio y la arquitectura del antepié, debe estudiarse el morfotipo del retropié. El tratamiento médico es principalmente podoortésico. Si persisten los síntomas, el tratamiento quirúrgico tiene como objetivo corregir la etiología de la insuficiencia del primer radio.
... Check whether the feet are symmetrical, whether there are claw-toe deformities, and whether the range of motion of the forefoot, hindfoot, ankle, and toes are normal. Check whether the "peek-a-boo" sign [25,26] is obvious. 3. Identify the deforming forces involved [27]. ...
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Article
Objective: Cavus foot is a deformity defined by the abnormal elevation of the medial arch of the foot and is a common but challenging occurrence for foot and ankle surgeons. In this review, we mainly aim to provide a comprehensive evaluation of the treatment options available for cavus foot correction based on the current research and our experience and to highlight new technologies and future research directions. Methods: Searches on the PubMed and Scopus databases were conducted using the search terms cavus foot, CMT (Charcot-Marie-Tooth), tendon-transfer, osteotomy, and adult. The studies were screened according to the inclusion and exclusion criteria, and the correction of cavus foot was analyzed based on the current research and our own experience. At the same time, 3D models were used to simulate different surgical methods for cavus foot correction. Results: A total of 575 papers were identified and subsequently evaluated based on the title, abstract, and full text. A total of 84 articles were finally included in the review. The deformities involved in cavus foot are complex. Neuromuscular disorders are the main etiologies of cavus foot. Clinical evaluations including biomechanics, etiology, classification, pathophysiology and physical and radiological examinations should be conducted carefully in order to acquire a full understanding of cavus deformities. Soft-tissue release, tendon-transfer, and bony reconstruction are commonly used to correct cavus foot. Surgical plans need to be customized for different patients and usually involve a combination of multiple surgical procedures. A 3D simulation is helpful in that it allows us to gain a more intuitive understanding of various osteotomy methods. Conclusion: The treatment of cavus foot requires us to make personalized operation plans according to different patients based on the comprehensive evaluation of their deformities. A combination of soft-tissue and bony procedures is required. Bony procedures are indispensable for cavus correction. With the promotion of digital orthopedics around the world, we can use computer technology to design and implement cavus foot operations in the future.
... 28 The progression of bilateral idiopathic cavovarus is poorly understood when compared to neurologic cases. 19,29 Much like pes planus patients, adequate treatment of both feet in bilateral cases with orthotics, bracing, and potentially surgery may lead to improved function and quality of life. ...
Article
Background: The primary aim of this study was to determine the prevalence of asymptomatic pes planus and cavovarus foot deformities using the tripod index (TI). Methods: A retrospective study was conducted on 122 adult subjects over the age of 18 from January 2010 to December 2016 with symptomatic pes planus (n=78) or cavovarus (n=44) foot deformities. We subdivided both groups into subjects who presented with unilateral symptomatic deformities (pes planus unilateral symptomatic; cavovarus unilateral symptomatic) and bilateral symptomatic foot deformities (pes planus bilateral symptomatic feet and cavovarus bilateral symptomatic feet). The severity of TI was compared between sides. Results: The prevalence of asymptomatic pes planus and cavovarus foot deformities was 52% and 67.6%, respectively. Subjects with unilateral symptomatic foot deformities had significantly more severe TI values for the symptomatic cavovarus foot -98.96% (-288.89 to 0%) compared to asymptomatic cavovarus -67.41% (-270.59 to 14.71%) (p=0.015). Subjects with unilateral symptomatic pes planus deformity also had more severe TI on the symptomatic foot 57.49 (-9.38 to 141.67%) compared to the asymptomatic foot 30.43 (-51.52 to 119.23%) (p<0.01). Subjects with bilateral symptomatic foot deformities had no significant difference in severity of Tripod Index between feet. Conclusion: Although half of subjects with unilateral symptomatic deformities had a foot deformity on the contralateral side, the severity of deformity between symptomatic and asymptomatic feet was significantly different for both pes planus and cavovarus feet. Further studies should prospectively follow postoperative radiographs to determine whether a correction in foot alignment directly improves symptoms.Level of evidence: III.
... This may be due to lateral overload caused by the hindfoot varus but may also be due to lax lateral ankle ligaments. [16][17][18] Excessive loading on the lateral side of the ankle may lead to peroneal tendon symptoms including tendinopathy, tears, subluxations or dislocations. Anteromedial impingement between talar and tibial spurs has been described and appears to be more common in those with subtle cavus feet. ...
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Article
Cavovarus deformity can be classified by the severity of malalignment ranging from a subtle and flexible to a severe and fixed cavovarus deformity of the foot. In the mild cavovarus foot, careful clinical assessment is required to identify the deformity. Weight-bearing radiographs are necessary to indicate the apex of the deformity and quantify the correction required. Surgery is performed when conservative measures fail and various surgical procedures have been described, including a combination of soft-tissue releases, tendon transfers and osteotomies, all with the aim of achieving a plantigrade and balanced foot. Joint-sparing surgery is the best option in flexible cavovarus foot even in Charcot-Marie-Tooth (CMT) disease (peroneal muscular atrophy). Arthrodesis is indicated in severe rigid cavus foot or in degenerative cases. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160077. Originally published online at www.efortopenreviews.org
... The cavovarus foot type, even in its subtle form, increases the load on the external aspectlateral side of the foot, resulting in an increased risk of inversion injury. These individuals are prone to lateral ankle sprains and eventually chronic lateral ankle instability 13 . Although the gold standard to diagnose cavovarus foot has not been determined, it is generally accepted that plantar pressure measurements during static Page 4 of 24 Translational Sports Medicine 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 F o r R e v i e w O n l y Running title: Cavus feet pressure and soccer injuries 5 standing can objectively identify a cavovarus foot type 10 . ...
Article
Introduction The aim of this study was to determine if risk factors for foot or ankle injuries could be identified using quantitative foot measurements. Methods Male and female soccer players of all levels, from 9 to 40 years old were included in this cross‐sectional study. Soccer history, foot and ankle function and injury history were investigated. Foot symmetry, length and arch height flexibility and plantar pressure captured with a mat were measured. All variables showing a significant correlation (p ≤ 0.05) and the presence of at least one foot or ankle injury, were integrated into a multivariate logistic regression model using forward stepwise selection. Results We recruited 277 players (196 males) and 79 participants had sustained at least one foot or ankle soccer‐related injury. The significant variables were: age, gender, pressure on the lateral heel and on the fourth and fifth metatarsals. Based on the model, the area under the ROC curve was 81.2%. To achieve a specificity of 80%, the corresponding sensitivity was 72.2%. Conclusions Plantar pressure measurements can objectively assess foot alignment. Increased pressure on the lateral heel and fourth and fifth metatarsal cavovarus foot type, represent a risk factor for foot and ankle injuries in soccer.
Article
The authors dedicate this article to describing the clinical work-up and etiology for a cavus foot deformity as well as the surgical decision making for correction. Understanding and proper utilization of osteotomies is paramount in the improvement of cavus foot deformities. Also, the authors share their own experiences with preferred techniques for optimal outcomes. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
The nerve conduction characteristics of adults with idiopathic pes cavus/hammer toes have not been studied extensively. Among 2048 out-patients (59.5 ± 13.9 years) referring to a laboratory of Neurophysiology in Rome, we recruited 18 patients with idiopathic pes cavus (61.3 ± 12.5 years). Fifty-four age/sex-matched controls were also studied. No nerve conduction differences were observed between patients with and without cavus foot (p > 0.05). The absence of deep tendon reflexes and slight muscle weakness and hypotrophy in the lower limbs were more common in subjects with cavus foot deformity than in controls (p < 0.001). Adult patients with idiopathic pes cavus/hammer toes do not differ from healthy controls from a neurophysiological standpoint, but they could show minor signs of clinical impairment, such as lower limb weakness, hypotrophy and areflexia.
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Article
Total ankle replacement remains an option for varus and valgus ankles, provided that it results in a balanced, neutrally aligned ankle. Accurate preoperative assessment of the deformity is essential for appropriate selection of adjuvant procedures. Osteotomies performed proximal (tibial), within (malleolar), or distal to (calcaneal, metatarsal) the ankle, allow deformity correction. Outcomes can be expected to be as good as of those ankles without coronal plane malalignment, at least in the short-term.
Article
Foot and ankle injuries account for nearly one-third of running injuries. Achilles tendinopathy, plantar fasciopathy, and ankle sprains are 3 of the most common types of injuries sustained in runners. Other common injuries include other tendinopathies of the foot and ankle, bone stress injuries, nerve conditions including neuromas, and joint disease including osteoarthritis. This review provides an evidence-based framework for the evaluation and optimal management of these conditions to ensure safe return to running participation and reduce risk for future injury.
Article
Lateral ankle instability is one of the most common musculoskeletal disorders and can result in ankle damage. This study reports on the results of the anatomical reconstruction of ligaments using semitendinosus tendon allograft and bioabsorbable tenodesis screws for chronic lateral ankle instability, as well as the functional and radiological results of this procedure. From February 2007 to January 2013, 70 patients (72 ankles) underwent this procedure. Six patients were lost to follow-up, and ultimately 64 patients (66 ankles) were evaluated. Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot & Ankle Society (AOFAS) scores, Karlsson-Peterson ankle scores, and patient satisfaction were evaluated at a mean of 22.1 months (range, 12-68 months) postoperatively. The talar tilt angle and anterior translation were assessed radiographically in pre- and postoperative ankle stress views. The mean patient age at surgery was 30.1 years (range, 16-59 years). The mean VAS pain score decreased from 5.5 to 1.3 (P < .05), and the mean AOFAS improved from 71.0 to 90.9 (P < .05). The mean Karlsson-Peterson score improved from 55.1 to 90.3, whereas talar tilt decreased from 14.8 degrees to 3.9 degrees. There was no significant difference in clinical outcomes between the pretensioned and nonpretensioned groups. This procedure yielded successful results, including satisfactory ankle stability and clinical outcomes, in ankles with poor lateral ligament tissues. Level IV, case series. © The Author(s) 2015.
Article
Background: Lateralizing calcaneal osteotomy (LCO) is a frequently used technique to correct hindfoot varus deformity. Tibial nerve palsy following this osteotomy has been described in case reports but the incidence has not been quantified. Methods: Eighty feet in 72 patients with cavovarus foot deformity were treated over a 6-year span by 2 surgeons at their respective institutions. Variations of the LCO were employed for correction per surgeon choice. A retrospective chart review analyzed osteotomy type, osteotomy location, amount of translation, and addition of a tarsal tunnel release in relation to the presence of any postoperative tibial nerve palsy. Tibial nerve branches affected and the time to resolution of any deficits was also noted. Results: The incidence of neurologic deficit following LCO was 34%. With an average follow-up of 19 months, a majority (59%) resolved fully at an average of 3 months. There was a correlation between the development of neurologic deficit and the location of the osteotomy in the middle third as compared to the posterior third of the calcaneal tuber. We found no relationship between the osteotomy type, amount of correction, or addition of a tarsal tunnel release and the incidence of neurologic injury. Conclusions: Tibial nerve palsy was not uncommon following LCO. Despite the fact that deficits were found to be transient, physicians should be more aware of this potential problem and counsel patients accordingly. To decrease the risk of this complication, we advocate extra caution when performing the osteotomy in the middle one-third of the calcaneal tuberosity. Although intuitively the addition of a tarsal tunnel release may protect against injury, no protective effect was demonstrated in this retrospective study. Level of evidence: Level III, retrospective cohort study.
Chapter
Surgical correction of the cavovarus foot deformity can be extremely challenging. Not only are you dealing with a very complex foot structure but also understanding the neurological etiology is critical to a successful outcome. Cavovarus deformity can be caused from either static contracture or dynamic contracture. When treating patients with dynamic contractures, where there is a progressive nature to the deformity, long-term outcomes are especially difficult to predict [1]. Static contractures, on the other hand, are easier to predict, and treatment is more straightforward. This chapter is intended to identify the crucial elements of procedure selection, discuss technical pearls for the commonly performed reconstructive procedures to prevent complications, and review specific complications and ways to manage them effectively.
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Article
RESUMO Objetivo: Realizar uma revisão sobre o pé cavo, sua fisiopatologia, avaliação clínica, diagnósticos diferenciais com ênfase na doença de Charcot-Marie-Tooth e tratamento. Método: Revisão não sistemática de artigos abordando a fisiopatologia do pé cavo, avaliação clínica, diagnósticos diferenciais e tratamento. Resultados e discussão: Fo-ram utilizados 33 artigos de língua inglesa e 02 artigos em português para a confecção desta revisão. Conclusão: O pé cavo é geralmente secundário a doenças neurológicas, em especial a doença de Charcot-Marie-Tooth e raramente é originado por doenças não neurológicas. O diagnóstico etiológico do pé cavo permite um melhor tratamento, cirúrgico ou não, com adequada orientação ao paciente quanto ao prognóstico e eficácia da terapia. Palavras-chave: Doença de Charcot-Marie-Tooth, pé cavo, neuropa-tia motora e sensitiva hereditária. ABSTRACT Objective: We realize a review about cavus foot, discussing pathophy-siology, clinical evaluation, differential diagnosis with emphasis on Charcot-Marie-Tooth Disease and treatment. Method: We perform a non-systematic review of articles about cavus foot pathophysiology, physical examination, etiology and treatment. Results and discussion: We used 33 articles in english and 02 articles in portuguese for this review. Conclusion: The cavus foot is mostly a consequence of neurolo-gical etiologies, in particular Charcot-Marie-Tooth disease and rarely is caused by non-neurological diseases. The correct diagnosis allows better treatment, conservative or surgical, with appropriate guidance to patients in terms of prognosis and therapy effectiveness.
Article
A high longitudinal plantar arch, varus position of the heel, forefoot equinus, and pronation of the first ray are characteristic of a cavovarus deformity. Forefoot-driven and hindfoot-driven deformities are distinguished based on pathomechanics. In first ray strong plantarflexion, the forefoot touches the ground first. This leads to compensatory varus heel, lock of the midfoot, reduction of the flexible phase, and decrease in shock absorption. In hindfoot-driven cavovarus deformity, the subtalar joint may compensate for varus deformities above the ankle joint. Overload of the lateral soft tissue structures and degenerative changes may occur in longstanding cavovarus deformity.
Article
Mild to moderate cavus deformity creates a dilemma in terms of surgical decision-making. The decision to pursue osteotomy or arthrodesis is not always clear. This article provides a framework for guiding management of these deformities, followed by a detailed surgical approach to correcting moderate cavus deformities, which emphasizes the use of a midfoot osteotomy-arthrodesis.
Article
Patients who present with lateral ankle ligament instability always need to be evaluated for cavovarus foot deformity. Cavovarus reconstruction may need to be performed in order to ensure the ankle instability procedure is successful. Which procedures are required will depend on the specific deformity present, and may need to be determined intraoperatively depending on the initial deformity correction achieved through the first procedures performed. A general though not strict algorithm for sequence of procedures involves soft tissue releases first, followed by hindfoot correction, then forefoot correction, and securing ligament reconstruction or tendon transfers as the final step. Tendon transfers can be an effective tool to aid in the deformity correction and several are described. For hindfoot and forefoot deformity correction, traditional calcaneus and metatarsal osteotomies work well, but fusion should be considered for joints with degenerative change or in cases where the deformity is severe or can't be corrected through osteotomy alone.
Article
Background: Subtle cavus foot (SCF) is an entity characterized by mild cavus. However, few studies have examined whether a SCF may be a risk factor for chronic ankle instability (CAI). Methods: This study included 116 patients who underwent lateral ankle ligament repair (modified Broström operation) for CAI and 105 controls. We used the standing lateral radiograph, so compared calcaneal pitch angle, Meary's angle, heights of the first and fifth metatarsal bases, and fibular positions between groups. Additionally, two observers subjectively rated the standing lateral radiographs for the presence of SCF. Results: There were no significant intergroup differences in any of the radiographic angles. The prevalence of SCF was 20.7% in the CAI group and 18.1% in the control group according to observer 1 versus 21.6% and 28.6% (CAI group and control group, respectively) according to observer 2. There were no significant intergroup differences in the proportion of SCF between the two observers (p=0.105 and 0.211, respectively). Conclusion: SCF was not a significant risk factor for CAI when judging by standing lateral radiograph, and the detection of SCF seems to require considerable experience. Thus, care should be taken when determining whether to perform corrective osteotomies when treating CAI patients with SCF. Level of evidence: III, case control.
Chapter
Hindfoot arthrodesis is a powerful tool for the correction of severe pain and deformity in the foot and ankle; however, these procedures can result in nonunions or malunions which pose significant reconstruction challenges, with little evidence to guide treatment. Evaluation begins with a detailed history and physical, focusing on understanding the initial reason for arthrodesis and patient risk factors that may compromise healing. The patient’s medical status should be optimized prior to proceeding with revision. Imaging includes standard foot and ankle series, and advanced imaging with CT scanning is almost always necessary. The goal of reconstruction of a failed hindfoot arthrodesis is to achieve a plantigrade foot with solid union. Success can be achieved by restoring the normal anatomic and radiographic relationships of the hindfoot, midfoot, and forefoot. A variety of surgical techniques have been described. Regardless of technique, apposition of healthy bone ends with application of bone graft and rigid internal fixation are necessary for maintenance of deformity correction and solid fusion. After hindfoot correction, other deformities in the midfoot or forefoot may be unmasked. Additional procedures in the midfoot and forefoot may be needed to ensure that all deformity is addressed to achieve a plantigrade foot.
Chapter
The cavus foot is commonly associated with peroneal tendon pathology, and reconstruction of this deformity is often warranted in conjunction with peroneal surgery. Procedures must be individualized on the basis of the characteristics of the deformity. Newer methodologies for the evaluation of the cavus foot, including weight-bearing CT, may allow for more accurate patient selection and preoperative planning. Minimal incision techniques have recently been developed that minimize the risk associated with multiple simultaneous procedures on the lateral hindfoot.
Article
There is a deficiency in publications on the topic of midfoot cavus. The limited research available does not have a standard definition for the diagnosis of this deformity and lacks a reliable algorithm for its surgical management. The authors performed an extensive review of the literature that found a majority of patients are satisfied with the Cole osteotomy and the dorsiflexory first metatarsal osteotomy for treatment of this condition. High patient satisfaction has been observed with lateralizing calcaneal osteotomies in the setting of midfoot cavus with a secondary rigid rearfoot deformity. Further research on this topic is encouraged.
Article
Conditions of ankle instability, peroneal tendon tears, and stress fractures of the lateral metatarsals are commonly encountered in a clinical foot and ankle practice. Evaluation of the supporting foot structure is critical to prevent failure of index procedures. The prominence of the subtle cavus foot is now a recognized entity and must be properly diagnosed and addressed surgically.
Chapter
Pathology of the peroneal tendons is an underdiagnosed cause of lateral ankle pain. Tendinopathy of the peroneal tendons can be acute or chronic. Tendon partial tears can also occur. Physical exam and the use of radiographs, ultrasound, and magnetic resonance imaging (MRI) verify the pathology suspected based on the patient’s history and symptoms. Nonoperative management such as immobilization, bracing, nonsteroidal anti-inflammatory drugs (NSAIDs), lateral heel wedges, and physical therapy is traditionally attempted first for the management of tendinopathy. For patients who fail nonoperative management, there are several surgical options available including tendon debridement, tenosynovectomy, tendon tubularization, tendon grafting, or tenodesis. Depending on the pathology type, associated conditions including peroneal tendon subluxation, os perineum syndrome, cavovarus deformity, and lateral ankle instability should be addressed at the time of surgical management. Routine arthroscopic evaluation of the ankle is also recommended at the time of surgery to address any significant intraarticular pathology. With appropriate management, patients with pathology of the peroneal tendons have good outcomes.
Chapter
The neurologic cavus foot presents with a complex array of deformities caused by muscle imbalance leading to structural changes in the foot. Depending on the muscles which are weak or strong, the shape of the foot will be varied and include a cavus, cavovarus, cavoadductovarus, and cavoequinovarus. These deformities are always associated with muscle imbalance and soft tissue contracture. The treatment of the cavus foot must take into consideration the muscle imbalance since tendon transfers are always required. In addition, the bone is corrected at each apex noting that in many feet, there is more than one apex to the overall deformity. Regardless of the flexibility or rigidity of the hindfoot, midfoot, and forefoot, the structural changes of the foot and the principles of correction are the same, which is to balance the muscles forces, release contracted soft tissues, and correct the deformities with a combination of osteotomy or arthrodesis.
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Article
The electromyographic activity of the peroneus longus and anterior tibial muscles of 25 patients with chronic ankle instability (18 patients with bilateral symptoms and 7 patients with unilateral complaints) and 10 controls was registered during the stance phase under different walking conditions. With balance secured by external support, there was a variable amount of peroneal activity, most of which was found in the third quarter of stance. A high increase in peroneus longus activity starting after foot-flat was found when subjects had to maintain balance in a natural way. No difference in peroneal activity was found in relation to instability complaints. It is thought that the peroneus longus serves to maintain balance, that this function decreases with increase of speed and that one cannot rely on this muscle to prevent an inversion injury during normal walking. The anterior tibial muscle was predominantly active in the first quarter after heel contact. An increase in activity in the second quarter as an effect of loss of secured balance suggests that this muscle plays some part in balance control, but this is not its main function. A significant increase in tibialis anterior activity was found in patients with bilateral instability. No significant difference was found between the symptomatic and asymptomatic leg of patients with unilateral instability under the same walking conditions. These findings suggest changes in central control.
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Article
To examine changes in the pattern of force transfer between the foot and the floor associated with chronically sprained ankles by measuring the peak forces and their timing under several regions of the feet during level walking. Twelve young male subjects (mean (SD) age 21 (2) years) with recurrent ankle sprains were studied. Seven of them had unilateral and bilateral chronic instability and laxity, and five had bilateral instability. Twelve healthy men (without orthopaedic or medical disease) served as a control group. Subjects walked at their own pace along a 7 m walkway, which included a Mini-EMED pressure distribution measuring system. The variables measured were relative peak force (fraction of body weight) and relative timing (fraction of stance time). These variables were measured under six regions of interest in each foot print: heel, midfoot, medial, central, and lateral forefoot, and toes. (a) A significant delay to the time of peak force under the central and lateral forefoot and toes in subjects with chronic ankle instability. (b) A significant decrease in the relative forces under the heel and toes and an increase in the relative forces under the midfoot and lateral forefoot in subjects with chronic ankle instability. (c) In the patients with unilateral instability, there were no significant differences in any of the variables between the injured and non-injured foot. In patients with chronic ankle instability, there is a slowing down of weight transfer from heel strike to toe off, a reduced impact at the beginning and end of the stance phase, and a lateral shift of body weight.
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Article
A cavovarus foot deformity was simulated in cadaver specimens by inserting metallic wedges of 15° and 30° dorsally into the first tarsometatarsal joint. Sensors in the ankle joint recorded static tibiotalar pressure distribution at physiological load. The peak pressure increased significantly from neutral alignment to the 30° cavus deformity, and the centre of force migrated medially. The anterior migration of the centre of force was significant for both the 15° (repeated measures analysis of variance (ANOVA), p = 0.021) and the 30° (repeated measures ANOVA, p = 0.007) cavus deformity. Differences in ligament laxity did not influence the peak pressure. These findings support the hypothesis that the cavovarus foot deformity causes an increase in anteromedial ankle joint pressure leading to anteromedial arthrosis in the long term, even in the absence of lateral hindfoot instability.
Article
Pes cavus is a descriptive term that covers a spectrum of deformity. It is often secondary to a neurological abnormality. Determination of the underlying aetiology and the pathoanatomy in the individual patient is essential to the prescription of the appropriate treatment in a particular patient. The goals of any treatment being a painless, plantigrade shoeable foot. The major anatomical component of the deformity and whether there is a hind or forefoot rigidity will help direct any required surgical intervention. Surgery is not an inevitable end point in the treatment of pes cavus and many patients are well treated by orthotic devices and shoe modification. If surgery is considered there is no universal set of guidelines. However, options that preserve joint movement are preferred–at least in the first instance–to procedures involving fusions and osteotomies that destroy joints, with arthrodesis reserved for salvage of failed correction or those with severe deformity.
Article
Chronic functional instability of the lateral ankle may be difficult to distinguish from mechanical instability when radiological stress test reveal only small ligamentous defects. When a decision for or against surgical reconstruction of the ligaments has to be made it can be helpful to use additional information on joint function. Therefore, a prospective study of 65 patients (mean age 24.1±4.6 years) with long-standing chronic ankle instability was conducted to demonstrate that the dynamic measurement of plantar pressure distribution can identify patients with functional ankle instability. Plantar pressure patterns were measured during gait by means of a capacitive platform, the EMED-SF system. The impulses at eight points of the foot were calculated intraindividually and compared with those in a group of 100 healthy subjects. On the basis of clinical criteria alone, the two groups of patients were distinguished, 35 with functional instability and 30 with mechanical instability. The patients with functional instability showed significantly increased lateral loading of the unstable foot (P=0.01), whereas the group with mechanical instability tended to walk more on the medial side of the unstable foot. This finding is explained by a deficit or peroneal strength during the stance phase, based on a proprioceptive deficit after trauma. The new technique provides additional information, which is relevant and sufficiently important to help in making decisions about the individual patient with chronic instability
Article
Varus ankle associated with instability can be simple or complex. Multiple underlying diseases may contribute to this complex pathologic entity. These conditions should be recognized when attempting proper decision-making. Treatment options range from conservative measures to surgical reconstruction. Whereas conservative treatment might be a possible approach for patients with simple varus ankle instability, more complex instabilities require extensive surgical reconstructions. However, adequate diagnostic workup and accurate analysis of varus ankle instability provide a base for the successful treatment outcome.
Article
In summary, varus deformity of the foot and ankle encompasses a spectrum of deformities from mild to severe. The cause of this deformity may be bone, muscle imbalance, or a combination of both. Surgical intervention should be planned only after the patient's anatomy is understood. Uncorrected symptomatic varus deformities may have significant consequences on gait kinematics and foot biomechanics.
Article
Peroneal tendon pathology is rare, but is probably underestimated because it is frequently undiagnosed. It should always be in the differential diagnosis of lateral ankle pain. Surgical treatment of peroneal tendinopathy is indicated after failure of conservative measures. The aim of this retrospective study is to evaluate the medium-term clinical results of 17 patients operated for peroneal tendinopathy without tendon subluxation. A series of 17 patients composed of 7 women and 10 men with a mean age of 53.6 ± 4.6 (range 45 to 60) years were reviewed. The mean preoperative Kitaoka score was 46.7 ± 17.1 (range 25 to 69) points. All patients had radiological evaluation, which demonstrated hindfoot varus in 6 of the 17. Surgical interventions comprised synovectomy, debridement, suture-tubularization, fibrous resection, or tenodesis depending on the preoperative findings and also a valgus osteotomy (Dwyer) in 6 cases and ankle ligament reconstruction (modified Blanchet) in 1 case. All patients were reviewed clinically with a mean follow-up of 4.3 ± 3.8 years (range 16 months to 14 years). Average time to return to sport was 8.5 ± 10.4 months (range 3 months to 3 years). The mean time to return to work was 2.5 ± 1.9 (range 0 to 6) months. The mean postoperative Kitaoka score was 90.1 ± 11 (range 64 to 100) points with a statistically significant improvement to the preoperative score (p < .0001). Sixteen patients were satisfied or very satisfied with their treatment (94.1%). Surgical treatment of peroneal tendinopathy after failed conservative treatment leads to significantly improved function. It is a simple treatment to undertake, which gives a good outcome for both the patient and surgeon.
Article
Subtle cavovarus foot is a condition that can lead to significant foot pain and disability. We review the results of our treatment algorithm at medium-term followup. Thirty-five consecutive patients with lateral based symptoms due to an underlying congenital subtle cavovarus foot type were surgically corrected. Various procedures were utilized, including some combination of the following: lateral displacement calcaneus osteotomy, peroneus longus to brevis transfer, dorsiflexion first metatarsal osteotomy, and Achilles tendon lengthening. Twenty-three patients, with 29 feet, returned for followup examination. The mean patient age at the time of surgery was 43.4 years, and the mean followup to date was 4.4 years. The mean AOFAS ankle hindfoot score preoperatively was 45, and postoperatively was 90. Radiographically, the medial cuneiform to floor height changed from 3.5 cm preoperatively to 3.0 cm postoperatively. The talo-first metatarsal angle improved 7.5 degrees postoperatively. There were no nonunions. No patients to date have gone on to fusions or revisions. Ten feet (34%) required hardware removal. All patients had resolution of their symptoms following hardware removal. The surgical management for the subtle cavovarus foot based on the proposed treatment algorithm provided symptomatic relief, longstanding correction, and high patient satisfaction.
Article
This study investigated the use of a custom cavus foot orthosis (CFO) in the treatment of ankle instability and pain associated with the subtle cavus foot, a common pathological foot alignment in the United States population. Patients referred by a single orthopedic foot and ankle surgeon to a single pedorthotist for a CFO over a 2-year period were eligible. Pain score pre-and postorthosis and number of instability events pre- and postorthosis were retrospectively evaluated. Ninety-three of 174 eligible patients participated. Average age was 48 years (range, 20-75) and patients suffered a variety of foot pathologies. Average pre-CFO pain score was 7.22 (0 no pain, 10 worst pain). Post-CFO pain score average was 2.41 (p < .0005). Ninety-two percent of patients reporting ankle instability as a problem experienced a decrease in the frequency of instability events post-CFO. The custom cavus foot orthosis is effective at relieving pain and reducing ankle instability in the patient with the subtle cavus foot alignment.
Article
95 patients operated on for chronic lateral ankle instability were compared for possible foot deformities with 34 normal persons. All the feet underwent a standardized radiographic examination. Measurements of three defined angles on a lateral nonweight-bearing radiograph indicated higher foot arches in the instability group than in the control group. Benink's tarsal index showed a higher frequency of cavovarus deformities in the instability group. © 1990 Informa UK Ltd All rights reserved: reproduction in whole or part not permitted.
Article
Various radiographic measurements of the normal adult foot have been reported in both early and recent literature; however, a complete description of radiographic quantitative data has yet to be reported. The purpose of this study is to describe the range of the normal foot using standard radiographic techniques that can be applied to the clinical setting. This should provide the data necessary for the accurate interpretation of foot radiographs. This study demonstrates the wide variation in bony relationships of the normal adult foot. When certain recognized criteria of radiographic measurements were evaluated, some were found to be defined as too narrow or inaccurate. Most importantly, because of this wide range, surgical procedures to produce radiographic homogeneity are not indicated. Treatment should be directed specifically toward areas of pain and not radiographic appearance.
Article
It is widely accepted that persons with flat or high-arched feet are at increased risk of exercise-associated injury, even though this purported association has not been scientifically evaluated. We evaluate the risk of exercise-associated injury among young men with flat, normal, and high-arched feet. A prospective study of 246 US Army Infantry trainees followed up over a rigorous 12-week training program. All subjects were evaluated prior to onset of training. Evaluation included photographs of the right, weight-bearing foot that were digitized and utilized to make several measures of arch height. An army initial entry training center. All trainees beginning army training on 2 successive weeks were potential volunteers. There were no criteria for exclusion other than declining to participate (n = 3). The subjects were healthy, active young men with a mean age of 20.3 years. The occurrence of a lower-extremity musculoskeletal injury resulting in a visit to and a diagnosis by an army physician or physician assistant. Treating physicians and physician assistants were blind to participation status and were not study staff members. On univariate analysis, there was an association between arch height and risk of injury using several alternative operational definitions of foot type. The 20% with the flattest feet were at the lowest risk (reference group; odds ratio, 1.0), with adjusted odds ratios for any musculoskeletal injury of 3.0 (P < .05) for the middle 60% group and 6.1 (P < .05) for the highest 20% group. These findings do not support the hypothesis that low-arched individuals are at increased risk of injury, and they have implications for runners, exercise enthusiasts, and clinicians. It may be possible to prevent substantial morbidity among active populations by identifying individuals at high risk and advising alternate activities.
Article
Nine patients with rigid equinocavovarus contractures of the foot and ankle after ischemic episodes of the leg were treated from 1986 to 1989. The ischemic contractures occurred after tibial and fibular fractures in six cases, and after a trimalleolar ankle fracture, an electrical burn, and cardiac bypass surgery in one case each. Previous tendon and nerve releases had failed. The scarred portion of the various involved muscles of the deep posterior compartment were widely excised along with the respective tendons. A variety of additional foot procedures were generally necessary to obtain a plantigrade foot. Night splinting to maintain a plantigrade foot was prescribed for all patients.
Article
The purpose of this prospective study was to determine whether an association exists between foot structure and the development of musculoskeletal overuse injuries. The study group was a well-defined cohort of 449 trainees at the Naval Special Warfare Training Center in Coronado, California. Before beginning training, measurements were made of ankle motion, subtalar motion, and the static (standing) and dynamic (walking) characteristics of the foot arch. The subjects were tracked prospectively for injuries throughout training. We identified risk factors that predispose people to lower extremity overuse injuries. These risk factors include dynamic pes planus, pes cavus, restricted ankle dorsiflexion, and increased hindfoot inversion, all of which are subject to intervention and possible correction.
Article
We carried out an experiment to measure the relationship between tensile force in the tendoachilles and plantar fascia strain, and how this relationship is affected by the metatarsophalangeal joint dorsiflexion angle. Eight cadaver lower extremity specimens underwent biomechanical testing. Using a servo-hydraulic testing machine, a tensile force up to 500 N was applied to the tendoachilles while the strain on the plantar fascia was measured using an extensometer. The experiment was repeated at four different metatarsophalangeal joint dorsiflexion angles (0 degrees, 5 degrees, 30 degrees, and 45 degrees). Measurements and calculations showed that dorsiflexion of the toes tightens the plantar fascia (the windlass effect) and increases the effect that a tensile force in the tendoachilles has on the tensile strain and tensile force in the plantar fascia.
Article
Dynamic pedobarography (DPB) was performed in 21 patients, 9 male and 12 female with cavovarus foot deformity mostly of Charcot-Marie-Tooth origin. Age ranged from 14 to 52 years (mean 30 y). Twenty-six feet were examined pre- and postoperatively clinically, radiologically and by dynamic pedobarography with a follow-up time from 9 to 49 months (mean 22.5 mo). The EMED SF system was used for data collection during walking. Gait line, contact areas (CA), peak pressures (PP) and pressure time integral (PTI) were determined. According to the contact pattern the examined feet could be divided into three groups with antegrade, retrograde and inversion contact pattern. Data analysis showed postoperatively considerable increase in CA and decrease in PP and PTI. Clinical results such as plantar callosities and "roll over avoidance gait" did not always correlate with pedobarographic data. DPB adds a dynamic component in the diagnosis and management of cavovarus feet but certain limitations exist.
Article
The purpose of this study was to determine if high-arched and low-arched runners exhibit different injury patterns. Non-randomized, two-group injury survey. Running-related injuries are thought to be related, in part, to lower extremity structure. High-arched and low-arched runners with their different bony architecture may exhibit very different lower extremity mechanics and, consequently, different injury patterns. It was hypothesized that high-arched runners will exhibit a greater incidence of lateral injuries, skeletal injuries and knee injuries while low-arched runners will show a greater incidence of medial injuries, soft tissue injuries and foot injuries. Twenty high-arched and 20 low-arched runners were included in this study. Running-related injuries were recorded and divided into injury patterns of medial/lateral, bony/soft tissue and knee/foot and ankle for both high-arched and low-arched runners. A chi(2) analysis was then employed in an attempt to associate injury patterns with arch structure. High-arched runners reported a greater incidence of ankle injuries, bony injuries and lateral injuries. Low-arched runners exhibited more knee injuries, soft tissue injuries and medial injuries. Based on these results, high and low arch structure is associated with different injury patterns in runners. Relevance. Different injury patterns are present in individuals with extreme high arches when compared to those with extremely low arches. These relationships may lead to improved treatment and intervention strategies for runners based on their predisposing foot structure.
Article
Chronic functional instability of the lateral ankle may be difficult to distinguish from mechanical instability when radiological stress test reveal only small ligamentous defects. When a decision for or against surgical reconstruction of the ligaments has to be made it can be helpful to use additional information on joint function. Therefore, a prospective study of 65 patients (mean age 24.1+/-4.6 years) with long-standing chronic ankle instability was conducted to demonstrate that the dynamic measurement of plantar pressure distribution tan identify patients with functional ankle instability. Plantar pressure patterns were measured during gait by means of a capacitive platform, the EMED-SF system. The impurses at eight points of the foot were calculated intraindividually and compared with those in a group Of 100 healthy subjects. On the basis of clinical criteria alone, the two groups of patients were distinguished, 35 with functional instability and 30 with mechanical instability. The patients with functional instability showed significantly increased lateral loading of th; unstable foot (P=0.01), whereas the group with mechanical instability tended to walk more on the medial side of the unstable foot. This finding is explained by a deficit or peroneal strength during the stance phase, based on a proprioceptive deficit after trauma. The new technique provides additional information, which is relevant and sufficiently important to help in making decisions about the individual patient with chronic instability.
Article
Cavovarus foot can be painful and disabling owing to deformity and instability. A method of surgical correction is presented with osteotomies of the forefoot and the hindfoot. The technique avoids arthrodesis while preserving joint motion, lowering the height of the arch, and correcting varus and adductus deformity. Increased ankle stability, elimination of the risk of stress fracture, decreased pain are expected outcomes.
Article
A prospective case-control study was performed comparing axial and coronal CT scan images of 11 patients (14 ankles) with chronic lateral instability and 12 controls. Scans were performed in a standardized fashion to simulate weight-bearing. Nine measurements to evaluate the alignment of the hindfoot and forefoot were made on two occasions by two observers. The blinded images were read in order of assigned random number. The angle between the calcaneus and the vertical plane showed a statistically significant difference between patients (6.4 +/- 4 degrees varus from vertical) and controls (2.7 +/- 5 degrees) using unpaired ANOVA (p < 0.01). Intra-observer (R2 = 0.49 +/- 0.19) and interobserver (R2 = 0.71 +/- 0.13) variation showed moderate reliability across all measurements. This study demonstrates a method to evaluate hindfoot varus on CT scan. Many factors have been studied (e.g., proprioception) as the cause for recurrent instability, and this is the first time, to our knowledge, that an anatomic cause has been demonstrated. Although calcaneal osteotomy is clearly not indicated routinely, it may have a role in correcting extreme varus, which may contribute to failed ligament reconstruction in patients with ankle instability.
Article
1 . A new surgical approach to the treatment of pes cavus is suggested. The operation consists in a subcutaneous division of the contracted plantar fascia and correction of the varus deformity of the heel by removing a wedge from its lateral aspect. It is submitted that, by approaching the deformity from behind and overcoming the varus of the heel, the foot is rendered plantigrade and that thereafter weight bearing exerts a corrective influence which results in progressive improvement of the deformity. The operation is essentially a prophylactic one and, for the best results, it should be performed before there is gross structural deformity and while active growth is still taking place. 2. Even in patients over the age of fourteen, improvement is obtained by doing nothing more than this simple operation. In the presence of fixed deformity of the forefoot, as encountered in older patients, inversion is corrected by removing a lateral wedge from the calcaneum and the cavus by taking a dorsal wedge from the tarso-metatarsal region. This has the double advantage of producing good correction of deformity, while at the same time preserving movement at the mid-tarsal-subtalar joint. Fixed clawing of the toes will require appropriate corrective treatment, but if the toes are malleable the simple effect of weight bearing on the plantigrade foot produces gradual correction.
Article
The purpose of this study was to quantify differences in joint range of motion, foot deformity, and foot morphology among pes cavus, neutrally aligned, pes planus rigid, and pes planus flexible feet. A cohort of 1047 veterans with diabetes (contributing 2047 feet) was enrolled in a prospective study of diabetic ulcer risk factors (the Seattle Diabetic Foot Study). Significant differences between foot types were found. Pes cavus feet had an increased percentage of prominent metatarsal heads, bony prominences, and hammer/claw toes (p < .0001), as well as significantly increased amounts of hallux dorsiflexion and decreased amounts of hallux plantarflexion (p < .0001) with a total range of motion equal to the other foot types (p = .3). Neutrally aligned feet had a lower percentage of intrinsic muscle atrophy, bony prominences, and hammer/claw toes (p < .0001). Pes planus feet had an increased lateral talometatarsal angle (p < .0001) and an increased second metatarsal length. These data demonstrate structural differences between foot types in a population with diabetes.
Article
The transverse tarsal plays a critical role in allowing the foot to transition from a flexible structure that dissipates impact as the foot strikes the ground and accepts the body's weight to the rigid structure that is required for efficient propulsion during toe off.Similarly, the medial longitudinal arch of the foot is controlled by the supportive structures of the talonavicular joint. A fine balance exists between muscular control and static support structures of the talonavicular joint. Failure of one support structure is often followed by fatigue of the remaining support and loss of function of the entire joint complex. This article describes the osseous and ligamentous anatomy of the talonavicular and calcaneocuboid joints and describes the biomechanical role of the transverse tarsal joint in standing and gait. Biomechanical principles are used to illustrate orthotic management of diseases that affect the transverse tarsal joint.
Article
The position of the fibula within the ankle mortise may be a factor contributing to recurrent ankle instability. The current study was performed to determine whether significant differences in fibular position exist in a population of patients who underwent lateral ankle stabilization procedures. The hypothesis that a fibula positioned posteriorly within the mortise predisposes the ankle to chronic instability was evaluated. Sixty-five CT/MRI scans of patients who underwent lateral ankle stabilization procedures from 1998 to 2001 were reviewed. The position of the fibula in relation to the tibia at the ankle mortise was expressed as the axial malleolar index (AMI). A greater AMI corresponds to a more posterior fibula. The AMI was also calculated from 65 CT/MRI scans performed on control patients who had no ankle instability. The average AMI in the study group was 17 degrees +/- 6 degrees (SD) compared with an average of 9 degrees +/- 4 degrees (SD) in the control group (p <.01). Therefore, the fibula was nearly twice as posterior in patients undergoing ankle reconstruction. In 42/65 (65%) study patients, the AMI was greater than 15 degrees. Only 5/65 (8%) control patients had AMI values greater than 15 degrees. This corresponds to an eightfold greater likelihood of AMI greater that 15 degrees in the instability group than in the control group. This study supports the hypothesis that a posteriorly positioned fibula predisposes to ankle instability.
Article
Subtle cavus foot deformity is ubiquitous, yet it continues to be commonly missed. Simple physical examination maneuvers can provide information that allows well-planned nonoperative care and selection of operative procedures to correct the underlying cause as well as presenting pathology.
Article
Clinical management of patients with painful pes cavus is challenging because the mechanism of foot pain is poorly understood. The purpose of this study was to explore the influence of various pes cavus aetiologies on foot pain and plantar pressure characteristics, and to identify the relationship between foot pain and plantar pressure. Seventy subjects were recruited for this study. They included 30 subjects with pes cavus of unknown aetiology (idiopathic), 10 subjects with pes cavus of neurological aetiology (neurogenic) and 30 subjects with a normal foot type. The presence and location of foot pain was recorded and barefoot plantar pressures were measured using the EMED-SF platform for the whole foot, rearfoot, midfoot and forefoot regions. Subjects with pes cavus of either idiopathic or neurogenic aetiology reported a higher proportion of foot pain (60%) compared to subjects with a normal foot type (23%) (P=0.009). Pressure-time integrals under the whole foot, rearfoot and forefoot regions in pes cavus, of both idiopathic and neurogenic origin, were higher than in the normal foot type (P<0.01). Pressure-time integrals in subjects reporting foot pain were higher than for pain free subjects (P<0.001). There was a significant correlation between pressure-time integral and foot pain (r=0.49, P<0.001). Foot pain is a common finding among individuals with pes cavus. Regardless of aetiology, pes cavus is characterized by abnormally high pressure-time integrals which are significantly related to foot pain. An understanding of the relationship between pes cavus pressure patterns and foot pain will improve the clinical management of these patients.
Article
Cavovarus foot deformity, which often results from an imbalance of muscle forces, is commonly caused by hereditary motor sensory neuropathies. Other causes are cerebral palsy, cerebral injury (stroke), anterior horn cell disease (spinal root injury), talar neck injury, and residual clubfoot. In cavovarus foot deformity, the relatively strong peroneus longus and tibialis posterior muscles cause a hindfoot varus and forefoot valgus (pronated) position. Hindfoot varus causes overload of the lateral border of the foot, resulting in ankle instability, peroneal tendinitis, and stress fracture. Degenerative arthritic changes can develop in overloaded joints. Gait examination allows appropriate planning of tendon transfers to correct stance and swing-phase deficits. Inspection of the forefoot and hindfoot positions determines the need for soft-tissue release and osteotomy. The Coleman block test is invaluable for assessing the cause of hindfoot varus. Prolonged use of orthoses or supportive footwear can result in muscle imbalance, causing increasing deformity and irreversible damage to tendons and joints. Rebalancing tendons is an early priority to prevent unsalvageable deterioration of the foot. Muscle imbalance can be corrected by tendon transfer, corrective osteotomy, and fusion. Fixed bony deformity can be addressed by fusion and osteotomy.
Article
Symptomatic lateral ankle instability is a common source of disability in an active population. While most incidences are successfully treated by conservative measures, some individuals require lateral ankle reconstruction. A commonly performed procedure is the Gould modification of the Broström lateral ankle reconstruction. Despite its success, some individuals experience recurrent instability through reinjury. Revision surgery often involves nonanatomic reconstruction using tendon grafts that may restrict normal ankle and subtalar motion and can result in persistent postoperative pain and disability. The purpose of this study was to demonstrate an equivalent success rate using a more anatomic revision lateral ankle reconstruction based on the Gould modification of the Broström concept. We retrospectively reviewed 15 consecutive patients who had a revision lateral ankle reconstruction between 1992 and 2000. All procedures were done by a single surgeon (FGL). Patients who exhibited hindfoot varus and dynamic heel rollout had a valgus calcaneal osteotomy. Patients were asked to complete a 100-point questionnaire postoperatively. All patients reported improvement in ankle function, decreased pain, and no episodes of instability compared to preoperative assessments. Excellent results were achieved in 12 of 15 patients which was consistent with published data from index Broström reconstructions. Four patients who had fixed hindfoot varus and dynamic ankle rollout had valgus calcaneal osteotomies. All patients returned to an active lifestyles including sports and military service. Our findings suggest that a revision anatomic lateral ankle reconstruction is an effective option. A thorough clinical evaluation was mandatory to assess hindfoot valgus with dynamic ankle rollout for which a valgus calcaneal osteotomy was included in the procedure. We believe that tendon sacrificing procedures can be avoided in most patients, but soft-tissue structures must be assessed intraoperatively and the surgical approach planned to allow for conversion if necessary.
Article
Chronic lateral ankle instability has been associated with varus deformity of the hindfoot, hyperactivity of the peroneus longus muscle, and insufficiency of the lateral ligaments. Many operative procedures have been described to correct this problem, but instability can recur if all contributing components are not treated. The purpose of this study was to offer an approach in the diagnosis and treatment of recurrent lateral ankle instability. Eight consecutive patients (nine feet) were treated for recurrent chronic lateral ankle instability. The average age at surgery was 25 (range 8 to 37) years. All patients had prior operative procedures that failed and had persistent pain and functional instability of the ankle joint. After clinical and radiographic examination, lateralizing calcaneal osteotomy to correct the structured varus deformity and peroneus longus to peroneus brevis tendon transfer to add dynamic correction were done in all patients. A Broström ligament reconstruction was added in four feet. All patients were evaluated clinically and radiographically at an average followup of 37 months. Preoperatively and postoperatively patients were evaluated by means of the American Orthopaedic Foot and Ankle Society (AOFAS) Score. All patients were satisfied with the operation. The overall AOFAS-Score improved from 57 points preoperatively to 87 points postoperatively. Hindfoot alignment was restored to a valgus position at final evaluation. Recurrent chronic lateral ankle instability often is associated with chronic hindfoot malalignment and leads to functional impairment and patient discomfort. Clinical examination should determine the causes of instability. Varus malalignment of the hindfoot, hyperactivity of the peroneus longus muscle, and insufficiency of the lateral ligaments should be assessed and treated in a combined operative procedure to correct structured, static and dynamic components of the instability. The preliminary results of this particular approach are encouraging.
Article
Ankle sprains have a high incidence of associated injuries and conditions that may be unrecognized at the initial time of injury. Failure to treat these conditions at the index surgery may compromise outcomes and delay recovery. The purpose of this study was to determine the type and frequency of associated injuries and conditions in military patients with chronic lateral ankle instability. Between 1996 and 2002, 160 patients had 180 modified Broström-Gould lateral ankle ligament reconstructions for chronic ankle instability. A retrospective review of the clinical history, physical examination, radiographs, and intraoperative findings was conducted. The overall incidence of associated extra-articular conditions and injuries found in this study was 64%; 115 conditions were identified in 180 ankles. Peroneal tendon injuries occurred with the highest frequency (28%), followed by os trigonum lesions (13%), lateral gutter ossicles (10%), hindfoot varus alignment (8%), anterior tibial spurs (3%), and tarsal coalitions (2%). Twenty revision lateral ankle ligament reconstructions were required for either persistent pain or recurrent instability. The most common associated conditions were undiagnosed hindfoot varus alignment abnormalities (28%) followed by untreated peroneal injuries (25%). This study confirms the frequency of conditions associated with lateral ankle instability and emphasizes several conditions that have received little attention in the literature. Identifying these associated conditions before surgery enables the surgeon to treat all conditions at one operation, returning the patient to full activity sooner. Guidelines are presented to assist clinicians in screening patients for these associated conditions.
Article
The subtle cavus foot alignment is associated with many injuries occurring in the athletic population, most commonly ankle instability and lateral foot overload. Although correction of the primary injury may address the manifestations of the subtle cavus foot, it does not change the alignment. Without recognition of this alignment, the injury likely will recur. The goal is to recognize the posture of the subtle cavus, treat the cavus and the injury, and prevent future recurrence.